Reduction in Hospitals' Readmission Rates: Role of Hospital-Based Skilled Nursing Facilities

Implementation of a Multimodal Heart Failure Management Protocol in a Skilled Nursing Facility

Hospitals and skilled nursing facilities (SNFs) are incentivized to reduce hospital readmissions among patients with heart failure (HF). We used the RE-AIM framework and mixed quantitative and qualitative data to evaluate the implementation of a multimodal HF management protocol (HFMP) administered in a SNF in 2021. Over 90% of eligible patients were enrolled in the HFMP (REACH). Of the 42 enrolled patients (61.9% female, aged 81.9 ± 8.9 years, 9.5% Medicaid), 2 (4.8%) were readmitted within 30 days of hospital discharge and 4 (9.5%) were readmitted within 30 days of SNF discharge compared with historical (2020) rates of 16.7% and 22.2%, respectively (a potential savings of $132,418-$176,573 in hospital costs) (EFFECTIVENESS). Although stakeholder feedback about ADOPTION and IMPLEMENTATION was largely positive, challenges associated with clinical data collection, documentation, and staff turnover were described. Findings will inform refinement of the HFMP to facilitate further testing and sustainability (MAINTENANCE).

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

IMPORTANCE

Health care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate.

OBJECTIVE

To determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022.

EXPOSURES

Treatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey.

MAIN OUTCOMES AND MEASURES

Rates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics.

RESULTS

A total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, -$275 [95% CI, -$15 to -$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P < .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

Factors Influencing Admission Decisions in Skilled Nursing Facilities: A Retrospective Quantitative Study (Preprint)

BACKGROUND

Occupancy rates within skilled nursing facilities (SNFs) in the United States have reached a record low. Understanding drivers of occupancy, including admission decisions, is critical for assessing the recovery of the long-term care sector as a whole. We provide the first comprehensive analysis of financial, clinical, and operational factors that impact whether a patient referral to an SNF is accepted or denied, using a large health informatics database.

OBJECTIVE

Our key objectives were to describe the distribution of referrals sent to SNFs in terms of key referral- and facility-level features; analyze key financial, clinical, and operational variables and their relationship to admission decisions; and identify the key potential reasons behind referral decisions in the context of learning health systems.

METHODS

We extracted and cleaned referral data from 627 SNFs from January 2020 to March 2022, including information on SNF daily operations (occupancy and nursing hours), referral-level factors (insurance type and primary diagnosis), and facility-level factors (overall 5-star rating and urban versus rural status). We computed descriptive statistics and applied regression modeling to identify and describe the relationships between these factors and referral decisions, considering them individually and controlling for other factors to understand their impact on the decision-making process.

RESULTS

When analyzing daily operation values, no significant relationship between SNF occupancy or nursing hours and referral acceptance was observed (P>.05). By analyzing referral-level factors, we found that the primary diagnosis category and insurance type of the patient were significantly related to referral acceptance (P<.05). Referrals with primary diagnoses within the category "Diseases of the Musculoskeletal System" are least often denied whereas those with diagnoses within the "Mental Illness" category are most often denied (compared with other diagnosis categories). Furthermore, private insurance holders are least often denied whereas "medicaid" holders are most often denied (compared with other insurance types). When analyzing facility-level factors, we found that the overall 5-star rating and urban versus rural status of an SNF are significantly related to referral acceptance (P<.05). We found a positive but nonmonotonic relationship between the 5-star rating and referral acceptance rates, with the highest acceptance rates found among 5-star facilities. In addition, we found that SNFs in urban areas have lower acceptance rates than their rural counterparts.

CONCLUSIONS

While many factors may influence a referral acceptance, care challenges associated with individual diagnoses and financial challenges associated with different remuneration types were found to be the strongest drivers. Understanding these drivers is essential in being more intentional in the process of accepting or denying referrals. We have interpreted our results using an adaptive leadership framework and suggested how SNFs can be more purposeful with their decisions while striving to achieve appropriate occupancy levels in ways that meet their goals and patients' needs.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database

BACKGROUND

There are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.

AIM

To determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.

METHODS

We performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis.

RESULTS

The thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.

CONCLUSION

We found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

Does Geographic Location Affect the Quality of Care? The Difference in Readmission Rates Between the Border and Non-Border Hospitals in Texas

Purpose

Materials and Methods

Results

Conclusion

Analysis on the Effect of the Rehabilitation Intervention-Centered Targeted Nursing Model on the Cardiac Function Recovery and Negative Emotions in Patients with Acute Myocardial Infarction

Rehabilitation intervention which refers to the functional training by caregivers with the aid of specialized nursing techniques and the progressive promotion of patients' training initiative, with the purpose of improving mobility and quality of life, is of great significance. The purpose of the study was to investigate the effect of the rehabilitation intervention-centered targeted nursing model on the cardiac function recovery and negative emotions in patients with acute myocardial infarction (AMI). A total of 120 AMI patients admitted to our hospital between January 2019 and January 2020 were selected as the study subjects and randomly divided into group A (n = 60) and group B (n = 60), in which the group B patients received routine nursing combined with rehabilitation intervention, while based on the treatment in group B, the patients in group A underwent rehabilitation intervention-centered targeted nursing model. Then, the cardiac function indexes, negative emotion score, levels of risk factors for heart failure, complication rate (CR), and the quality of life (QOL) of the patients were compared between the two groups. The cardiac function indexes of the patients after nursing in group A were significantly better than those in group B (P < 0.001); the negative emotion scores of the patients after nursing in group A were significantly lower than those in group B (P < 0.001); the levels of risk factors for heart failure of the patients after nursing in group A were significantly lower than those in group B (P < 0.001); the CR of the patients in group A at 15 d and 30 d after admission was significantly lower than that in group B (P < 0.05); the QOL scores of the patients after nursing in group A were significantly higher than those in group B (P < 0.001). Rehabilitation intervention-centered targeted nursing model can optimize cardiac function, weaken the levels of risk factors for heart failure, reduce the incidence of complications, improve psychological conditions, and enhance the quality of life in AMI patients, which is worthy of application and promotion in clinical practice.

Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?

INTRODUCTION

Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment.

OBJECTIVES

This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access.

METHODS

We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access.

RESULTS

A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures.

CONCLUSIONS

In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.